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Breastfeeding Practices, Facilitators, and Barriers among Immigrant Muslim Arab Women Living in a Metropolitan Area of the Southwest of United States by Wafa Khasawneh A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Approved December 2016 by the Graduate Supervisory Committee: Pauline Komnenich, Chair Megan Petrov Elizabeth Reifsnider Azza Ahmed ARIZONA STATE UNIVERSITY May 2017 ABSTRACT Scientific evidence strongly indicates that there are significant health benefits of breastfeeding. Lower breastfeeding initiation, duration, and exclusivity rates are found in vulnerable populations particularly among women of low socioeconomic status, and racial minorities such as immigrant, racial, and minority cultural groups. Breastfeeding disparities can contribute to negative health outcomes for the mothers, and their infants, and families. Muslim Arab immigrants are a fast-growing, under-studied, and underserved minority population in the United States. Little is known about breastfeeding practices and challenges facing this vulnerable population. Immigrant Muslim Arab mothers encounter breastfeeding challenges related to religion, language, different cultural beliefs, levels of acculturation, difficulties understanding health care information, and navigating the health care system. A cross-sectional descriptive study was used to describe infant feeding practices, and identify contributors and barriers to adequate breastfeeding using the social ecological model of health promotion. A convenience sample of 116 immigrant Muslim Arab women with at least one child, 5 years or younger was recruited from a large metropolitan area in the Southwestern United States. The results indicated that immigrant Muslim Arab mothers demonstrate high breastfeeding initiation rates (99.2%), and lengthy breastfeeding duration (M=11.86), but low rates of exclusive breastfeeding at 6 months (21.6%). Facilitators to breastfeeding within the sample were high intentions to breastfeed, positive breastfeeding knowledge and beliefs related to the benefits of breastfeeding, religious teachings promoting breastfeeding, and encouragement to i breastfeed from the mothers’ social support system. Several barriers to successful breastfeeding were related to lacking the specific knowledge of the benefits of breastfeeding, and discomfort with breastfeeding in public, and in front of strangers. High income and religious teachings encouraging breastfeeding were significantly associated with exclusive breastfeeding at six months. Greater maternal age and comfort with breastfeeding in public were associated with longer breastfeeding durations. The socio-cultural context for support of breastfeeding is an important consideration by healthcare providers caring for Muslim Arab women. An ecological perspective needs to be applied to interventions targeting breastfeeding promotion to facilitate effectiveness in this population. Culturally tailored intervention to the specific breastfeeding concerns and needs of Muslim immigrant women could promote optimal breastfeeding in this population. ii DEDICATION بِ ْس ِم َّللا ِ ال ّر ْح َم ِن ال ّر ِحيم َو َما تَ ْوفِي ِقي إِل ّ بِا ّ للِ َع َل ْي ِه تَ َو ّك ْل ت َوإِ َل ْي ِه أ نِيب "In the name of God, most Gracious, most Compassionate" “And my success can only come from Allah; in Him I trust, and unto Him I return” (Quran 11:88) All thanks and praise is due to Allah, my Lord, we seek His help and forgiveness. We seek refuge in Allah from the evil within ourselves and the consequences of our evil deeds. Whoever Allah guides will never be led astray, and whoever Allah leads astray will never find guidance. This work is dedicated to my family, my mother and father, sisters, and brothers for their love, and constant support and encouragement. iii ACKNOWLEDGMENTS The Prophet Muhammad, peace and blessings be upon him, said “He has not thanked Allah who has not thanked people”. I would like to thank Drs. Elizabeth Reifsnider, and Pauline Komnenich my dissertation chairpersons, for your leadership, encouragement, and guidance. The sharing of your expertise was invaluable to me. I wish to express my sincere appreciation to my committee members, Dr. Megan Petrov and Dr. Azza Ahmed for the excellent guidance they provided during this research process. Your collaboration and engagement were instrumental in completing this thesis. I also want to thank Dr. Joan Dodgson for her input and guidance through the development stages of this research. Special thanks to Drs. Carolyn Graff and Elizabeth "Betsy" Tolley at University of Tennessee Health Science for being a constant source of support and encouragement. I will be forever grateful to you for the dedication you put forth to help me complete my doctoral study. I feel honored to have had this opportunity to learn from you, and I am deeply appreciative of all you have done for me. Thank you, Levi Colton, at the College of Nursing for your guidance and support throughout this program. I would like to thank all my friends for their encouragement and support throughout my study. Most importantly, I would like to thank all the mothers who agreed to participate in this study and made the completion of this research possible. iv TABLE OF CONTENTS Page LIST OF FIGURES ............................................................................................................ x INTRODUCTION .............................................................................................................. 1 Statement of the Problem ........................................................................................ 2 Purpose of the Study and Research Questions ........................................................ 3 LITERATURE REVIEW ................................................................................................... 5 Benefits of Breastfeeding ........................................................................................ 5 Factors Influencing Breastfeeding Practices ........................................................... 7 Individual Factors. ...................................................................................... 8 Social Factors. ............................................................................................. 9 Physical Environment. ................................................................................ 9 Societal Factors ......................................................................................... 10 Breastfeeding in Vulnerable Populations .............................................................. 11 Immigrant Muslim Arab Women in the US. ............................................ 13 Islamic Values and Breastfeeding ............................................................. 14 Challenges of Breastfeeding in Immigrant Muslim Arab Women ........... 18 Ecological Approach in Breastfeeding Research .................................................. 19 Conceptual Framework ............................................................................. 23 Definition of Terms............................................................................................... 26 v Page METHODS ....................................................................................................................... 28 Research Design.................................................................................................... 28 Sample................................................................................................................... 28 Setting ................................................................................................................... 29 Subject Recruitment .............................................................................................. 29 Data Collection ..................................................................................................... 30 Measurements ....................................................................................................... 31 Demographic Information ......................................................................... 32 Breastfeeding Knowledge and Beliefs ...................................................... 33 Infant Feeding Practices. ........................................................................... 33 Social Support ........................................................................................... 34 Religious Influence. .................................................................................. 35 Physical Environment ............................................................................... 35 Procedures ............................................................................................................. 32 Human Subjects Protection ................................................................................... 36 Data Analysis ........................................................................................................ 38 RESULTS ......................................................................................................................... 41 Characteristics of Sample ..................................................................................... 41 vi Page Research Question 1: Infant Feeding Practices .................................................... 44 Research Question 2: Facilitators and Barriers to Breastfeeding ......................... 48 Individual level. .......................................................................................
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